complaint·February 10, 2026

Due to staff negligence, resident missed medications. The MAR review revealed the C medication was not administered on October first, second and seventh at 12p.m. MAR review revealed that the C medication was on administered on October sixth or ninth at 8p.m. The MAR review also revealed the C medication was not administered on October eight or ninth for 10p.m. shift, with no notations on MAR for missing medications. During the investigation with staff interviews it was reported that medication was not given as the facility had run out of oral syringes. Staff five stated we did run out of oral syringes and I used one from house three, some of the other staff didn’t know to go borrow from house three, so the medication was not given. Staff five stated there were medication technicians that were afraid to give R1 his pain medication, stating that it was too much. Staff four stated when R1’s medication was put in the computer incorrectly and medications were missed because they didn’t show up on his list of medications for R1. Staff four stated there was a few times R1 didn’t receive his medication as I was not trained in how to crush it and put it in a syringe. Record review revealed the facility was out of stock for three of the residents’ medications, one of the medication was out of stock for seven days. Record review revealed multiple medications on multiple days were not recorded as given. Substantiated. Due to lack of supervision, resident was wedged between the bed/wall in an unsafe situation. It was reported that the resident was wedged between the wall and bed moaning in pain with no care staff insight. Staff four stated R1 didn’t like his feet covered and he would kick his feet off the bed trying to get the blankets off of his feet. Staff three S3 stated I heard about that, S3 stated the bed was supposed to be up against the wall and locked. S3 stated the bed wasn’t locked because that is how R1 scooted between the bed and the wall. Staff six stated I’ve seen R1 get wedged more than once, he is trying to get to the chair. Substantiated. Due to staff neglect, resident was left to lye in feces for an extended period of time. It was reported that the resident was found with dried feces and a rash on lower extremities. During the interview process S4 stated I have witnessed poo left on the residents, but not sure if it was R1. S2 stated it should have been recorded in the care note for that day, when R1 was toileted. S3 stated one time I witnessed that R1 was soiled, and I could tell it had been for quite a while. S2 stated yes, I heard about this from another staff, saying family complained and we need to check R1 every hour or two. S4 stated hospice residents should be checked every 30 minutes when they are at end of life. S7 stated I would come to work in the morning and R1 was soiled with feces was dried on, R1’s sheets would be soaked and the place smelled. S7 stated it happened numerous times and I reported it to my supervisor. The residents care plan states R1 is incontinent of bowels and needs to be checked throughout the shift for any bowel movements. LPA was unable to perform record reviews for BMs as the facility is unable to provide the BM records. Substantiated. Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.